Tuesday, April 11, 2017

Seeking to win buy-in from the Freedom Caucus for Paul Ryan's ACA repeal bill, the American Health Care Act, Republicans are considering removing protections for people with pre-existing conditions. According to an HHS analysis, over 130 million Americans, or 51% of the non-elderly population, have pre-existing conditions that could have made it impossible for them to obtain coverage in the pre-ACA individual market for health insurance -- or that, more precisely, "could have resulted in denial of coverage, exclusion of the condition, or higher premiums for individuals seeking individual market coverage before the ACA protections applied" (see Note 1 below).

Building on that analysis, which broke out the frequency of pre-existing conditions by age group, the Center for American Progress has produced estimates of the percentage and total number of people with such conditions in every Congressional District in the country (based on the age breakout in every district, not on regional health differences).

Charles Gaba has begun mapping the percentage with pre-ex conditions in each district (usually close to 50% ) to marketplace enrollment, estimating how many would be at risk from medical underwriting should guaranteed issue be repealed. Since it will take the Gabacus a while to reach New Jersey, I've produced a breakout for the state, with a couple of methodological variations:

I've included estimates for total individual market enrollment, outside as well as inside the ACA marketplace. That's based on a Milliman estimate that 61% of NJ individual market enrollment is through the marketplace -- see Note 2 below.

I've also included a column with the number of beneficiaries of the ACA Medicaid expansion, because should the AHCA pass, those enrollees will lose access to Medicaid and so potentially be subject to medical underwriting should they look to the individual market for coverage (though NJ did have guaranteed issue pre-ACA). See Note 3 below for source info.

The individual market and Medicaid expansion enrollment totals come to slightly over a million. That's just shy of one seventh of the total nonelderly population in the state. Roughly half of them presumably have pre-existing conditions -- perhaps more, as they are lower income on average than those with access to employer-sponsored insurance.

After too much ado, then, here are estimates by NJ Congressional District of people with pre-existing conditions (HHS broader measure), individual market enrollment as of 1/31 (subtract 10-13% for current enrollment), and Medicaid enrollment via the ACA expansion or pre-ACA waiver/

One major caveat: pre-ACA, New Jersey was one of just five states plus the D.C. that did provide guaranteed issue in its individual market. Insurers could subject applicants to a waiting period of up to 12 months for coverage of their condition, however, if they had not maintained continuous coverage prior to enrollment. And guaranteed issue without an individual mandate made coverage in the state extremely expensive -- so expensive that NJ was one of just a handful of states where average unsubsidized premiums dropped when the ACA marketplace opened.

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Note 1: The Kaiser Family Foundation has estimated more conservatively that 27% of Americans have pre-existing conditions that would have made coverage impossible to obtain in the individual market in the vast majority of states (45 allowed medical underwriting). The HHS study finds, similarly, that 23% of the population would have been deniable based on the criteria for coverage in pre-ACA high risk pools. The 51% figure pertains to the "broader measure" defined as quoted above. That broad measure checks out roughly with my own review of surveys indicating that pre ACA, roughly a third of people who needed coverage in the individual market were either denied or discouraged from seeking it; a third of those who did obtain it were charged above-market rates; and a smaller though indeterminate percentage were insurance that excluded coverage for their pre-existing condition.

Note 2: The health insurance consultancy Milliman recently provided estimates of the size of enrollment in each state's individual market outside of the ACA marketplace. Since all individual market enrollees would be exposed to medical underwriting, I've used the broader individual market enrollment estimate. In New Jersey, Milliman estimates that 61% of New Jersey enrollment is through the marketplace. I took estimates of current marketplace enrollment by district as of 1/31/17 from Charles Gaba, here. The marketplace enrollment for each district is 61% of the totals recorded below. Milliman's totals are lower because the firm estimates average monthly enrollment for the year, anticipating attrition. For average monthly enrollment, you could take 79% of the estimates below. For current enrollment, Gaba points out that in each of the last two years, marketplace attrition by 3/31 has been about 13%; whether it's the same for off-marketplace, I don't think anyone knows.

Note 3: The Medicaid expansion numbers per Congressional district are courtesy of a report produced last fall by Raymond Castro of New Jersey Public Policy. They include people who obtained coverage in NJ Family Care through pre-ACA Medicaid waivers that have since expired; these enrollees would also lose coverage under repeal of the expansion.

About Me

I'm a freelance writer and media consultant with a lasting interest in how democracy works, how it malfunctions and self-corrects. Since fall 2013 I've focused increasingly on the unfolding drama of Affordable Care Act implementation and health reform more generally.
I have a Ph.D. in medieval English literature and a propensity to parse the rhetoric and logic of our political leaders as well as that of media pundits and scholars who jump into the national debate. I wrote a dissertation on the remarkably humane and subtle medieval English anchorite Julian of Norwich, a mystic nun whose knack of squaring circles and framing paradoxes reminds me a little of our current president. A sampling of that work (mind the google gaps) is here: http://bit.ly/OzwsrR